Low Well-Being Is an Independent Predictor for Stroke in Elderly Patients with Diabetes Mellitus

Diabetes Distress Is Associated With Future Risk of Progression of Diabetic Nephropathy in Adults With Type 2 Diabetes: A Prospective Cohort Study (Diabetes Distress and Care Registry at Tenri [DDCRT23])

OBJECTIVES

Our aim in this study was to investigate the prospective association between diabetes distress assessed with Problem Areas in Diabetes (PAID) survey scores at baseline and the subsequent risk of development or progression of diabetic nephropathy in people with type 2 diabetes.

METHODS

Longitudinal data were acquired from 2,845 individuals with type 2 diabetes registered in a Japanese diabetes registry. A Cox proportional hazards model was used to adjust for possible confounders to examine the prospective association between baseline diabetes distress (PAID score ≥40) and the development or progression of albuminuria.

RESULTS

Mean patient age, body mass index, and glycated hemoglobin level were 64.8 years, 24.5 kg/m2, and 57.4 mmol/mol (7.5%), respectively. We did not observe a significant association between diabetes distress and the subsequent risk of diabetic nephropathy development from normoalbuminuria to microalbuminuria/macroalbuminuria (multivariable-adjusted hazard ratio [HR]=0.95 over 4.2 years, 95% confidence interval [CI] 0.77 to 1.17, p=0.640); however, we identified a significant association for progression from microalbuminuria to macroalbuminuria (multivariable-adjusted HR=1.34 over 7.0 years, 95% CI 1.01 to 1.80, p=0.045). Stratification by sex revealed a significant association between diabetes distress and the subsequent risk of progressing diabetic nephropathy (HR=1.45, 95% CI 1.06 to 1.98, p=0.019) in males, but not females (HR=1.42, 95% CI 0.95 to 2.14, p=0.087).

CONCLUSIONS

Diabetes distress at baseline, assessed using the PAID survey, was associated with a subsequent risk of progressing diabetic nephropathy independent of possible confounders in males, but not females, with type 2 diabetes.

A review of psychosocial factors and stroke: A new public health problem

The role of psychosocial factors (PSF) in increased risk of stroke is a novel public health challenge, but unclear definitions for PSF and the multiple stroke subtypes have led to inconsistent reports. A review of this issue is therefore warranted.

METHODS

Several databases were used for this narrative systematic review (Medline, Embase and Cochrane Library). Two independent reviewers evaluated articles from between 2001 and 2018 on the themes of PSF and stroke/transient ischemic attack (TIA). PSF criteria were job strain, psychological interpersonal and behavioral stress, and social deprivation. Ischemic and hemorrhagic stroke and TIA subtypes were also identified.

RESULTS

Forty-five cohorts, five case-control studies and two meta-analyses were included. Despite mixed results, PSF were associated with an increased risk of ischemic and hemorrhagic stroke in populations of all ages, and more predominantly in women.

CONCLUSION

This broad review shows that the presence of PSF is associated with an increased risk stroke and TIA. As such, PSF must figure in both public health policy and stroke prevention programs, similar to other established metabolic and environmental factors.

Association between poor psychosocial conditions and diabetic nephropathy in Japanese type 2 diabetes patients: A cross-sectional study

AIMS/INTRODUCTION

It is suggested that a positive psychosocial condition has a good effect on health and glycemic control. However, there has been no research to evaluate the association between positive psychosocial factors and diabetic nephropathy (DN). The aim of the present study was to evaluate the association between psychosocial factors and DN in patients with type 2 diabetes.

MATERIAL AND METHODS

To assess psychosocial condition, six indicators (happiness score, Life Orientation Test-revised score as an indicator of dispositional optimism, laughter frequency, self-awareness of stress, social network and social support) were assessed by a self-administered questionnaire, and associations between these psychosocial indicators and the presence of DN were examined.

RESULTS

A cross-sectional analysis of patients with (n = 123) and without DN (n = 220) showed that a high score for happiness (odds ratio [OR] per 1 standard deviation 0.71, 95% confidence interval [CI] 0.57-0.89, P = 0.003), high Life Orientation Test-revised score (OR per 1 standard deviation 0.77, 95% CI: 0.61-0.98, P = 0.035), less self-awareness of stress (OR 0.56, 95% CI: 0.34-0.90, P = 0.017), high connection of social network (OR 0.55, 95% CI: 0.35-0.87, P = 0.010) and high social support (OR 0.61, 95% CI: 0.38-0.96, P = 0.035) were associated with a reduced risk of prevalence of DN. Similar results were observed even after adjustment for the following conventional risk factors of DN: age, sex, duration of diabetes, hemoglobin A1c, hypertension, dyslipidemia and current smoking.

CONCLUSIONS

The present study showed that five out of six prespecified indicators of psychosocial condition were significantly associated with the presence of DN in Japanese patients with type 2 diabetes.

Survey of Hypoglycemia in Elderly People With Type 2 Diabetes Mellitus in Japan

Background

The number of elderly type 2 diabetes mellitus (T2DM) patients in Japan is increasing continuously. Hypoglycemia is a significant issue in their treatment. However, the actual situation and related details of their hypoglycemia remain unclear. In order to elucidate them, the Japan Physicians Association conducted a large-scale questionnaire survey for physicians and their outpatients all over Japan.

Methods

Targeted elderly T2DM outpatients were 65 years old or older in 2011. Specialized questionnaire survey forms were distributed to both of physicians and patients. The forms for physicians included questions whether patient had hypoglycemia in the last 1 month or 1 year; those for patients included whether they experienced it in the same durations and any of the 28 symptoms that are suggestive of hypoglycemia or pertaining to geriatric syndrome in the last 1 month, as well as questions about knowledge regarding hypoglycemia. We analyzed associations between hypoglycemia and the symptoms, and between hypoglycemia and medications.

Results

Of 15,892 T2DM patients (age, 74.2 ± 6.3 years; diabetes duration, 12.8 ± 8.9 years; HbA1c, 7.0±1.0%), dipeptidyl peptidase-4 inhibitor (DPP-4i) was the most prescribed medication among all oral hypoglycemic agents (OHAs). The frequencies of hypoglycemia in the last 1 month recognized by physicians and experienced by patients were 7.8% and 10.4% (P < 0.0001), and in the last 1 year were 15.5% and 21.1% respectively (P < 0.0001). The most common symptom was “weakness, fatigue/feeling languid” and the majority of all patients reported neuroglycopenic or autonomic symptoms. Regarding monotherapy, hypoglycemia was observed in 32.7% of the patients with insulin, 4% in sulfonylurea (SU), 3.8% in glinide, and 3.5% in pioglitazone. The questions asking knowledge about hypoglycemia revealed that SU or insulin users had significantly more knowledge of hypoglycemia than others (P < 0.001); however, 63% of patients using insulin, and 31% of patients using SU always carried glucose or a similar medication with them.

Conclusions

The present study suggested two types of “hidden hypoglycemia”, one is that physicians did not detect and the other one is that patients were not aware. It is vital that physicians strive to prevent hypoglycemia by paying closer attention to symptoms of “hidden hypoglycemia” in their elderly patients.

Epidemiology of diabetes and diabetes complications in the elderly: an emerging public health burden

Diabetes in the elderly is a growing public health burden. Persons with diabetes are living longer and are vulnerable to the traditional microvascular and macrovascular complications of diabetes but also at increased risk for geriatric syndromes. Peripheral vascular disease, heart disease, and stroke all have a high prevalence among older adults with diabetes. Traditional microvascular complications such as retinopathy, nephropathy, and neuropathy also frequently occur. Unique to this older population is the effect of diabetes on functional status. Older adults with diabetes are also more likely to experience geriatric syndromes such as falls, dementia, depression, and incontinence. Further studies are needed to better characterize those elderly individuals who may be at the highest risk of adverse complications from diabetes.

Patient attributes warranting consideration in clinical practice guidelines, health workforce planning and policy

Background

In order for clinical practice guidelines (CPGs) to meet their broad objective of enhancing the quality of care and supporting improved patient outcomes, they must address the needs of diverse patient populations. We set out to explore the patient attributes that are likely to demand a unique approach to the management of chronic disease, and which are crucial if evidence or services planning is to reflect clinic populations. These were incorporated into a new conceptual framework; using diabetes mellitus as an exemplar.

Methods

The patient attributes that informed the framework were identified from CPGs, the diabetes literature, an expert academic panel, and two cross-disciplinary panels; and agreed upon using a modified nominal group technique.

Results

Full consensus was reached on twenty-four attributes. These factors fell into one of three themes: (1) type/stage of disease, (2) morbid events, and (3) factors impacting on capacity to self-care. These three themes were incorporated in a convenient way in the workforce evidence-based (WEB) model.

Conclusions

While biomedical factors are frequently recognised in published clinical practice guidelines, little attention is given to attributes influencing a person's capacity to self-care. Paying explicit attention to predictable threats to effective self-care in clinical practice guidelines, by drawing on the WEB model, may assist in refinements that would address observed disparities in health outcomes across socio-economic groups. The WEB model also provides a framework to inform clinical training, and health services and workforce planning and research; including the assessment of healthcare needs, and the allocation of healthcare resources.

Long-term lifestyle intervention lowers the incidence of stroke in Japanese patients with type 2 diabetes: a nationwide multicentre randomised controlled trial (the Japan Diabetes Complications Study)

AIMS/HYPOTHESIS

The aim of the study was to clarify whether a therapeutic intervention focused on lifestyle modification affected the incidence of vascular complications in patients with established diabetes.

METHODS

A total of 2,033 eligible Japanese men and women aged 40-70 years with type 2 diabetes from 59 institutes were randomised to a conventional treatment group (CON), which continued to receive the usual care, and a lifestyle intervention group (INT), which received education on lifestyle modification regarding dietary habits, physical activities and adherence to treatment by telephone counselling and at each outpatient clinic visit, in addition to the usual care. Randomisation and open-label allocation were done by a central computer system. Primary analysis regarding measurements of control status and occurrence of macro- and microvascular complications was based on 1,304 participants followed for an 8 year period.

RESULTS

Although status of control of most classic cardiovascular risk factors, including body weight, glycaemia, serum lipids and BP, did not differ between groups during the study period, the incidence of stroke in the INT group (5.48/1,000 patient-years) was significantly lower than in the CON group (9.52/1,000 patient-years) by Kaplan- Meier analysis (p=0.02 by logrank test) and by multivariate Cox analysis (HR 0.62, 95% CI 0.39-0.98, p=0.04). The incidence of CHD, retinopathy and nephropathy did not differ significantly between groups. Lipoprotein(a) was another significant independent risk factor for stroke.

CONCLUSIONS/INTERPRETATION

These findings suggest that lifestyle modification had limited effects on most typical control variables, but did have a significant effect on stroke incidence in patients with established type 2 diabetes.

CLINICAL TRIAL REGISTRATION

UMIN-CTR C000000222

FUNDING

The Ministry of Health, Labour and Welfare, Japan

Diabetes mellitus and geriatric syndromes

Diabetes mellitus is associated with an increased prevalence and incidence of geriatric syndrome: functional disabilities, depression, fall, urinary incontinence, malnutrition and cognitive impairment. Geriatric syndrome not only leads to frailty, loss of independence and low quality of life, but also becomes a major obstacle in the treatment and care of diabetic people. The risk factors or contributing factors of geriatric symptoms are micro- and macrovascular complications, age-rated comorbid disease and aging per se. Comprehensive geriatric assessment of geriatric syndrome, including basic activities of daily living, instrumental activities of daily living, gait and balance, visual acuity, the Mini-Mental State Examination, depression scores, history and risk of fall, urination and nutrition, should be performed as part of the care of elderly diabetic patients, in particular old-old patients. Because geriatric syndromes are multifactorial and share risk factors, diabetic people with any geriatric symptoms should be treated with a common concentric strategy, such as supervised exercise therapy including muscle-strengthening training, psychological support, social support for adherence, and good glycemic control with avoidance of hypoglycemia.

Psychological wellbeing, physical impairments and rural aging in a developing country setting

BACKGROUND

There has been very little research on wellbeing, physical impairments and disability in older people in developing countries.

METHODS

A community survey of 1147 older parents, one per household, aged sixty and over in rural Thailand. We used the Burvill scale of physical impairment, the Thai Psychological Wellbeing Scale and the brief WHO Disability Assessment Schedule. We rated received and perceived social support separately from children and from others and rated support to children. We used weighted analyses to take account of the sampling design.

RESULTS

Impairments due to arthritis, pain, paralysis, vision, stomach problems or breathing were all associated with lower wellbeing. After adjusting for disability, only impairment due to paralysis was independently associated with lowered wellbeing. The effect of having two or more impairments compared to none was associated with lowered wellbeing after adjusting for demographic factors and social support (adjusted difference -2.37 on the well-being scale with SD = 7.9, p < 0.001) but after adjusting for disability the coefficient fell and was non-significant. The parsimonious model for wellbeing included age, wealth, social support, disability and impairment due to paralysis (the effect of paralysis was -2.97, p = 0.001). In this Thai setting, received support from children and from others and perceived good support from and to children were all independently associated with greater wellbeing whereas actual support to children was associated with lower wellbeing. Low received support from children interacted with paralysis in being especially associated with low wellbeing.

CONCLUSION

In this Thai setting, as found in western settings, most of the association between physical impairments and lower wellbeing is explained by disability. Disability is potentially mediating the association between impairment and low wellbeing. Received support may buffer the impact of some impairments on wellbeing in this setting. Giving actual support to children is associated with less wellbeing unless the support being given to children is perceived as good, perhaps reflecting parental obligation to support adult children in need. Improving community disability services for older people and optimizing received social support will be vital in rural areas in developing countries.

Stability of the Philadelphia Geriatric Center Morale Scale: A Multidimensional Item Response Model and Rasch Analysis

The purpose of this study was to explore the longitudinal structural and measurement invariance of the 17-item Philadelphia Geriatric Center Morale Scale (PGCMS) using a multidimensional item response model and the unidimensional Rasch model in contrast to prior work employing classical test theory. Participants ( n = 177) were assigned to three interventions and assessed at three time points. The structural analyses found that a 3-factor model fit better than a 1-factor or a 2-factor model using the Akaike information criterion (AIC) and Schwartz’s Bayesian information criterion (BIC) though not with the AICPC or the BIC PC. With respect to item fit, differential item functioning (DIF) and correlation of item logit positions, the PGCMS was quite stable. However, Items 4 and 5 were problematic in terms of fit. The internal consistency reliabilities of three factors were also relatively lower than desirable at one point and adequate at others.

Normal mortality in the elderly with diabetes under strict glycemic and blood pressure control: outcome of 6-year prospective study

Mortality, macroangiopathic events and end-stage renal disease (ESRD) in the elderly under long-term, intensive multifactorial diabetes control were prospectively investigated. Three hundred and eighty-eight elderly patients (> or =65 years) with type 2 diabetes (the mean age 72.9 years, men/women ratio 176/212) were followed-up for 6 years with HbA1c 7.0%, BP 145/80 mmHg and total cholesterol<240 mg/dl as targets. The mean baseline HbA1c was 6.8%, BP 137/74 mmHg and total cholesterol 196 mg/dl, and corresponding values upon closing 6.9%, 134/72 mmHg and 188 mg/dl respectively. Mortality rate was 19.6%/6 years (1.01 times that of age- and sex-matched general population), and macroangiopathic events developed in 142 (36.6%) and ESRD in 9 (2.3%). Independent risk factors: low glomerular filtration rate (GFR) (P<0.001), prior stroke (P=0.002), age (P=0.001) and DeltaBMI (P=0.001) for mortality; prior stroke (P<0.001) and coronary events (P=0.042), high LDL-cholesterol (P=0.004), low GFR (P=0.028), and past maximum BMI (P=0.032) and age (P=0.019) for macroangiopathy; low GFR (P<0.001) for ESRD. No smoking was an independent protective factor for mortality (P=0.008). In conclusion, normal mortality was attained in the elderly under intensive mutifactorial diabetes control. Renal dysfunction, prior stroke, high LDL-cholesterol, and prior obesity were prominent risks for mortality, macroangiopathy and/or ESRD.

Health related quality of life in older Mexican Americans with diabetes: a cross-sectional study

BACKGROUND

The older Hispanic population of the U.S. is growing at a tremendous rate. While ethnic-related risk and complications of diabetes are widely-acknowledged for older Hispanics, less is known about how health related quality of life is affected in this population.

METHODS

Cross-sectional study assessing differences in health related quality of life between older Mexican Americans with and without diabetes. Participants (n = 619) from the Hispanic Established Population for the Epidemiological Study of the Elderly were interviewed in their homes. The primary measure was the Medical Outcomes Study Short Form (SF-36).

RESULTS

The sample was 59.6% female with a mean age of 78.3 (SD = 5.2) years. 31.2% (n = 193) of the participants were identified with diabetes. Individuals with diabetes had significantly (F = 19.35, p < .001) lower scores on the Physical Composite scale (mean = 37.50, SD = 12.69) of the SF-36 compared to persons without diabetes (mean = 43.04, SD = 12.22). There was no significant difference between persons with and without diabetes on the Mental Composite scale of the SF-36.

CONCLUSION

Diabetes was associated with lower health related quality of life in older Mexican Americans. The physical components of health related quality of life uniformly differentiated those with diabetes from those without, whereas mental component scores were equivocal.

Disability and quality of life in elderly people with diabetes

To implement preventive policies of disability in older diabetic people, the role of diabetes in the disablement process should be investigated. Diabetes mellitus is consistently associated with a higher prevalence of disability at all states, as well as with a progression in disability states and may be considered as a brake on recovery. This association is partially explained by existing complications, associated conditions (obesity, depression, arterial hypertension) treatment burden, and other social characteristics (lower income, lower educational level). Finally, in the disablement process, the role of altered muscle metabolism due to diabetes, aging, nutrition and sedentary lifestyle may represent a major target for interventions to improve functions and potentially activities in elderly people.

Development, Worsening, and Improvement of Diabetic Microangiopathy in Older People: Six-Year Prospective Study of Patients Under Intensive Diabetes Control

OBJECTIVES

To examine retinopathy and nephropathy in elderly patients with diabetes mellitus (DM) under intensive multifactorial DM control.

DESIGN

Six-year interventional observation study.

SETTING

Multicenter study including four hospitals.

PARTICIPANTS

Four hundred thirteen elderly (> or = 65) patients with type 2 DM attending each hospital for 1 year or longer; those receiving hemodialysis or with uncured malignancy were excluded.

MEASUREMENTS

Development, worsening, and improvement of retinopathy and nephropathy and respective risk factors.

RESULTS

The mean baseline hemoglobin (HbA1c), blood pressure (BP), and total cholesterol were 6.8%, 137/74 mmHg, and 5.13 mmol/L, respectively. Retinopathy developed in 45 of 168 (27%) patients and, of 63 with nonproliferative retinopathy, worsened and improved in 11 (17%) and 23 (37%), respectively. Nephropathy developed in 53 of 227 (23%) patients and improved in 13 of 51 (25%) having it baseline. The mean change in glomerular filtration rate (DeltaGFR, baseline GFR-GFR at the end of the study period) in those with nephropathy at baseline was 21.5 mL/min. HbA1c was related to development of retinopathy (P=.001, odds ratio (OR)=1.91), and serum creatinine (P=.03, OR=1.02), systolic BP (SBP) (P=.03, OR=1.22), and prior stroke (P=.005, OR=3.21) were related to development of nephropathy. In patients with nephropathy at baseline, SBP (P=.03, Spearman's rho (rho)=0.310), total cholesterol (P=.01, rho=0.361), and low-density lipoprotein cholesterol (P=.03, rho=0.322) were correlated with DeltaGFR.

CONCLUSION

In elderly patients under intensive control for DM, the outcome of microangiopathy is favorable. Modifiable risk factors were hyperglycemia for development of retinopathy and hypertension and hypercholesterolemia for development or worsening of nephropathy; prior stroke was an unmodifiable risk factor for development of nephropathy.

Bem-estar subjetivo e senso de ajustamento psicológico em idosos que sofreram acidente vascular cerebral: uma revisão

Foi feito um levantamento dos estudos brasileiros e estrangeiros publicados entre 1996 e 2005 que relacionavam bem-estar subjetivo, senso de ajustamento psicológico e acidente vascular cerebral, com o objetivo de identificar variáveis mediadoras dessa relação em idosos. Estudos transversais e prospectivos indicaram que os afetados por acidente vascular cerebral apresentam menor bem-estar subjetivo quando comparados com a população geral. Boa capacidade cognitiva, suporte social efetivo, continuidade de uma ocupação produtiva, manutenção da competência em atividades instrumentais de vida diária e humor positivo são fatores que podem melhorar o bem-estar subjetivo e psicológico. Variáveis que podem piorar o bem-estar subjetivo e psicológico são incapacidade funcional, déficits cognitivos, depressão, dificuldade em restabelecer a identidade e restrição à possibilidade de desempenhar atividades e papéis que contribuem para a auto-definição. O conhecimento das implicações psicológicas de sofrer acidente vascular cerebral pode beneficiar pacientes, familiares e profissionais no gerenciamento do evento.

Validating a Self-report Measure of Global Subjective Well-being to Predict Adverse Clinical Outcomes

OBJECTIVES

To examine the relationship between a single-item indicator of subjective well-being (SWB) and (1) medical conditions frequently associated with adverse clinical outcomes, (2) health-related quality of life and depressive symptoms, (3) global self-rated health (SRH), and (4) increased risk of adverse clinical outcomes.

METHODS

Self-reports of depressive symptoms and HRQoL were obtained by mail surveys from 2,317 men and women with hypertension and coronary artery disease. Subjects rated their overall SWB at clinic visits. Mean scores of subjects reporting excellent SWB were compared to scores of subjects rating SWB for HRQoL domains and depressive symptom scores using ANOVA. The association between SWB and individual endpoints was assessed using the chi(2) test. The adjusted association between SWB and the composite endpoint of mortality, nonfatal stroke or nonfatal myocardial infarction was estimated using binary logistic regression.

RESULTS

Excellent SWB was associated with fewer depressive symptoms and more favorable HRQoL scores. The proportion of subjects suffering one of the adverse health outcomes within 1 year increased (p < 0.002) with poorer reported SWB. One-year mortality was higher in subjects with poor/fair SWB (5.7%) than in subjects with good or excellent SWB (3.4 and 4.5%, respectively; p = 0.05). Subjects rating their SWB as poor/fair were more likely to suffer a nonfatal stroke (unadjusted RR = 2.67, 95% CI = 1.24, 5.74). SWB added to the prediction of adverse outcomes after adjusting for demographics, baseline medical conditions, and SRH (OR = 2.49, 95% CI = 1.51, 4.11).

CONCLUSION

A global indicator of SWB may be a useful addition to a screening instrument for identifying persons at increased risk for adverse health outcomes.